a pathways community hub & systems change initiative

A Pathways Community HUB & Systems Change Initiative

• Social Determinants of Health

• Pathways Community HUB model overview

• How SDOH impact HUB clients

• ..are conditions in the places where people live, learn, work, and play that affect a wide range of health and quality-of life-risks and outcomes. -CDC

• “…as the conditions in which people are born, grow, live, work and age. These circumstances are shaped by the distribution of money, power, and resources at global, national, and local levels. …social determinants of health are mostly responsible for health inequities – the unfair and avoidable differences in health status seen within and between countries.” -WHO

Neighborhood

/Housing

Employment

Education

Healthcare

access/quality

Culture

Socioeconomic

Status/Income

Substance Use

• Social Determinants can contribute to substance use• “Several biological, social, environmental,

psychological, and genetic factors are associated with substance abuse. These factors can include gender, race and ethnicity, age, income level, educational attainment, and sexual orientation. Substance abuse is also strongly influenced by interpersonal, household, and community dynamics.” –Healthy People 2020

• Substance use can impact social determinants of health: • “Substance abuse—involving drugs, alcohol, or

both—is associated with a range of destructive social conditions, including family disruptions, financial problems, lost productivity, failure in school, domestic violence, child abuse, and crime. …Estimates of the total overall costs of substance abuse in the United States, including lost productivity and health- and crime-related costs, exceed $600 billion annually” – Healthy People 2020

• Lack of Social Determinants can be barriers to successful treatment or recovery• Health insurance/coverage

• Healthcare access/quality

• Transportation

• Access to technology

• Financial situation/Employment

• Support structures

• Stigma within the community

• Housing

• Social Determinants, for communities, often require systematic changes to impact communities/individuals

• Social Determinants are interconnected to other health outcomes

• Important to address barriers in communities to good health• Housing

• Food Access

• Financial opportunity/employment at fair wages

• Healthcare access

• Transportation

▪Uses existing community resources (medical and social) more efficiently and effectively

▪ Addresses both SDOH & clinical health metrics simultaneously

▪ Focuses on common metrics to identify and track risks (risk reduction)

▪Holistic community care coordination→one for the whole family

▪Outcome based

Agency A Agency B Agency C Agency D Agency E

• Needs new medical home

• 2 ED visits this month

• No asthma action

Plan

• Struggling at school

• Pregnant

• In recovery/treatment

• Lost job

• Can’t pay rent

• Unreliable

transportation

• One bedroom

apartment

• Type 2

Diabetes

• 1 ½ ppd

Smoker

Great Rivers HUB

• Shifting the responsibility of the system to FIND individuals vs individuals finding resources to help them

• Targeted referral sites

• Community Care Coordinators meet individuals where they are at

• Treat the “whole” person

• Each Risk = Pathway

• 20 Standard Pathways

• Finished Pathway = Outcome Achieved (Risk Factor Reduced/Eliminated) & Payment

• If outcome not achieved = Incomplete Pathway

• Outcome/value based payment

• Adult Education• Behavioral Health• Developmental Referral• Development Screening• Education• Employment• Family Planning• Health Insurance• Housing• Immunization Referral• Immunization Screening• Lead• Medical Home• Medical Referral• Medication Assessment Chart/ Medication

Assessment Pathway• Medication Management• Postpartum• Pregnancy• Smoking Cessation• Social Services Referral

• Based on community needs identified:• Frequent emergency room utilizer

• At-risk pregnant mother

• Elementary aged youth with chronic absenteeism

• La Crosse School District youth/family experiencing homelessness

• Cardiovascular Disease/Hypertension/Hyperlipidemia

• Type 2 Diabetes

• Total number of referrals: 654

• Total number of enrolled participants: 476

• Percentage of enrolled participants that identified addiction or substance use at referral: • 289/ 476 clients referred with substance use

identified= 61% (including tobacco and alcohol)

Pathway Opened Completed Finished- Incomplete

Adult Learning 11 2 9

Behavioral Health 59 27 25

Developmental Screening 1 1 0

Education 1233 1196 0

Employment 48 14 26

Family Planning 13 8 5

Health Insurance 41 27 9

Housing 144 48 55

Immunization Referral 15 4 6

Immunization Screening 42 27 2

Medical Home 72 35 12

Medical Referral 280 155 78

Medication Assessment 105 79 20

Medication Management 12 7 1

Postpartum 12 8 2

Pregnancy 17 15 1 (low birth weight)

Social Service Referral 1309 902 302

Tobacco Cessation 130 8 69

Top 5 Medical Referral for Clients with Substance Use

# of Referral Pathways Opened

Dental 100 (74% of total)

Mental Health 52 (66% of total)

Primary Care 31 (53% of total)

Vision 20 (80% of total)

Specialty Medical Care 19 (36% of total)

Top 5 Medical Referral for Total HUB Population

# of Referral Pathways Opened

Dental 136

Mental Health 77

Primary Care 58

Specialty Medical Care 53

Vision 25

Top 5 Social Service Referrals for Clients with Substance Use

# of Referral Pathways Opened

Transportation Assistance 204 (75% of total)

Food Assistance 151 (63% of total)

Clothing Assistance 143 (47% of total)

Financial Assistance 139 (66% of total)

Furniture Assistance 63 (63% of total)

Top 5 Social Service Referrals for Total HUB Population

# of Referral Pathways Opened

Clothing Assistance 300

Transportation Assistance 273

Food Assistance 238

Financial Assistance 210

Furniture Assistance 100

• Lindsey Purl, Director of Great Rivers HUB. lpurl@gruw.org

• Abby Waters, Operations Manager for Great Rivers HUB. awaters@gruw.org